Confidential Client Information And Health History For Chair Massage

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CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORY FOR CHAIR MASSAGE
First Name: _______________________ M.I. ______ Last Name: __________________________________________________
Address: __________________________City: ______________________ State: __________ Zip: _______________________
Phone (h): _____________________________________ (c): ______________________________________________________
Birth Date: ______ /______ /________________________ Email Address: __________________________________________
Employer: _________________________________ Occupation: _________________________________________________
Emergency Contact: __________________________________ Phone: ____________ Relationship: __________________
Please check if you have had any of the following:
Is this your first professional massage?
Yes
No
Arthritis, Tendonitis
Headaches/Migraines
If no, how often do you receive massage? __________
Cancer, Tumours
Allergies/Sensitivities
Please list current medication:
TMJ Problems
Skin Conditions
_____________________________________________________
Varicose Veins
Neck/Back Injuries
_____________________________________________________
Pregnancy
Heart Problems
_____________________________________________________
Blood Clots
Joint Problems
_____________________________________________________
Epilepsy
Circulation Problems
Do you have any ongoing or chronic pain? Explain:
Diabetes
Low Blood Pressure
_____________________________________________________
Paralysis
High Blood Pressure
_____________________________________________________
Fibromyalgia
Major Accident
_____________________________________________________
Numbness
Recent Injuries
_____________________________________________________
Sprains, Strains
Other ______________
Is there anything you would like to discuss today?
Explain any condition you have marked above:
_____________________________________________________
______________________________________________
_____________________________________________________
______________________________________________
_____________________________________________________
______________________________________________
_____________________________________________________
______________________________________________
I understand the benefits and risks of massage and give my consent for massage. It is also
understood that the massage practitioner has the right to refuse service to anyone. I will consult
my practitioner with any questions or concerns immediately. I have stated all medical conditions
that I am aware of and will keep my practitioner informed of any changes. I understand that the
purpose of this massage is to reduce stress and increase relaxation. I will immediately inform the
practitioner so that pressure and/or strokes may be adjusted to my level of comfort. I further
understand that massage/bodywork should not be construed as a substitute for medical
examination, diagnosis, or treatment and that I should see a physician, chiropractor or other
qualified medical specialist for any mental or physical ailment I am aware of.
Sign: __________________________________________________________________ Date: __________________________

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